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Pharmacovigilance

Adverse Reaction Report

Step 1 of 4

Information about the patient,
who experienced the adverse reaction

This report applies to*
myself a / my child a patient other person as follows

Initials*

Birth date or age*

Gender*
male female

Country

Height

Weight

* Mandatory field

Next
Step 2 of 4

Information about the product of ITALMED,
from which the adverse reaction is suspected

Name of the product (also strength/company, e.g. Amox, 1000mg)*

Batch number

Reason for use (e.g. pharyngitis, tonsillitis)

Dose (e.g. 1g, twice per day)

Type of administration (e.g. into the mouth)

Start of administration (yyyy/mm/dd)

Stop of administration (yyyy/mm/dd)

Are you still taking/using the product?

* Mandatory field

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Next
Step 3 of 4

Information about the
adverse reactions occurred

Date of initial occurrence of adverse reactions (yyyy/mm/dd)

Description of reactions / symptoms (e.g. skin rash, itching, fever etc.)*

Estimate the severity*
mild moderate severe

Characterise "severe" further
life-threatening persistent disability inpatient treatment required fatal other:

How is your/the condition, in relation to the adverse reaction, now?
completely recovered improvement of the reactions ongoing medical treatment other:

Did the reactions / symptoms resolve after withdrawal of the product?
yes no no information available

Did the reactions / symptoms repeat after re-administration of the same product?
yes no no information available

Was there a pregnancy while using the product?
yes no

Additional information, e.g. administration of other medication at the same time, previous known drug reactions, known allergies or intolerances, other present diseases, available results from laboratory tests etc.

* Mandatory field

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Next
Step 4 of 4

Contact details

Name*

Address

Phone number or email address*

By submitting the form you confirm to accept our privacy policy.

* Mandatory field

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